Sexually transmitted diseases in adolescents

Author
J Dennis Fortenberry, MD, MS
Section Editors
Amy B Middleman, MD, MPH, MS Ed
Sheldon L Kaplan, MD
Deputy Editor
Mary M Torchia, MD
Disclosures
Last literature review version 19.2: mayo 2011 | This topic last updated: marzo 21, 2011
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INTRODUCTION Adolescence is a heterogeneous developmental period in terms of
sexual behavior and risk of acquiring sexually transmitted diseases (STDs). Early
adolescence begins during the first years of the second decade and is marked by rapid
physical growth and attainment of secondary sex characteristics. Middle adolescence
begins at approximately age 14 years, ends around age 17 to 18 years, and is marked by
maturation of the reproductive systems and achievement of adult physical stature.
Increased sexual interest and noncoital sexual behaviors are characteristic of middle
adolescence.
The average age of first coitus is approximately 16 years among American adolescents,
but the age is lower in certain populations, such as inner city youth. Late adolescence
ends with the transition into young adulthood and is associated with high levels of
sexual activity and acquisition of STD.
This topic will focus on aspects of sexually transmitted diseases that are particularly
relevant in adolescents. Details about clinical manifestations, diagnosis, and treatment
of individual infections are discussed separately. (See appropriate topic reviews).
EPIDEMIOLOGY Cross-sectional data from the 2003-2004 National Health and
Nutrition Examination Survey (NHANES) indicate 24 percent of female adolescents
aged 14 to 19 years had laboratory evidence of at least one of the following STD:
human papillomavirus (HPV, 18 percent), Chlamydia trachomatis (4 percent),
Trichomonas vaginalis (3 percent), herpes simplex virus type 2 (HSV-2, 2 percent), or
Neisseria gonorrhoeae [1]. Among girls who reported ever having had sex, 40 percent
had laboratory evidence of one of the four STD, predominantly HPV (30 percent) and
chlamydia (7 percent).
Age-specific rates of acquisition of genital gonorrhea decreased in 2009. Rates were
568.8 per 100,000 population among women from 15 to 19 years of age, compared with
636.8 per 100,000 population in 2008 [2]. Genital chlamydia rates among 15- to 19year-old women were considerably higher, at 3329.3 per 100,000 in 2009.
Repeated acquisition of STD is common: as many as 40 percent of the annual incidence
of chlamydial or gonococcal disease occurs in adolescents previously infected with the
causative organisms. Many adolescents are reinfected within a few months of an index
infection [3,4].

Details about human immunodeficiency virus (HIV) infections in adolescents may be

found elsewhere. However, it is important to note that HIV is primarily an STD among
adolescents. (See "The adolescent with HIV infection".)
RISK FACTORS
Behavioral Behavioral factors have been linked to the increased risk of acquisition of
STD among adolescents, but biologic factors also may play a role.
Among the behavioral factors that have been associated with acquisition of STD in
adolescents are [4-10]:

Age at first sexual intercourse and time between menarche and first intercourse,
particularly for human papillomavirus (HPV). In an observational study of urban
adolescent females (14 to 17 years at enrollment), 25 percent were diagnosed
with an STD within one year of first intercourse [4]. Repeated infections were
common. These findings highlight the need for early initiation of STD screening
(within one year of first intercourse) and of retesting individuals who have been
infected every three to four months. (See 'Screening and diagnostic
testing' below.)
Sexual activity within early and middle adolescence, particularly for Chlamydia
trachomatis infection; 29 percent of sexually active inner-city adolescent
females in one study tested positive for Chlamydia, with 14-year-old adolescents
having the highest age-specific prevalence.

Multiple partners

New partners

Partners with multiple other partners

Inconsistent use of condoms, especially with established partners

Alcohol and other drug consumption (although this factor may track with poor
contraceptive use or multiple partners, rather than serving as an independent
marker of risky behavior).

Surveys of risk behaviors among high school students have shown a decline in sexual
experience and the prevalence of multiple sexual partners of 16 and 24 percent,
respectively, over the decade from 1991 to 2001 [11]. The prevalence of condom use
increased significantly between 1991 and 1999 and then plateaued.
Biologic Several biologic factors have been hypothesized to influence the
susceptibility of adolescents to acquisition of STD. One such factor is cervical ectopy or
cervical immaturity, which refers to the area of ectocervix that is covered by columnar
epithelium after puberty. Columnar epithelium is thought to be more susceptible than is
squamous epithelium (that replaces columnar upon maturation) to sexually transmitted
organisms such as Neisseria gonorrhoeae, C. trachomatis, and HPV. However, one study
could not demonstrate an independent association of cervical ectopy with STD among
adolescent women and, in fact, noted that an increased number of lifetime partners was
associated with a more mature cervix [12].

Secretory IgA (sIgA), a local protective antibody, is another postulated biologic factor.
Adolescents had slightly lower levels of sIgA in cervical mucus than did adult women
in one small study [13]. Another study addressing whether sIgA levels were higher in
the secretory phase of the menstrual cycle (a phase that frequently is absent in early
adolescence, when ovulation may not occur or may occur irregularly) found no
difference in levels in different phases of the adolescent menstrual cycle [14].
UNIQUE ISSUES IN ADOLESCENTS The evaluation and treatment of STD in
adolescents raises a number of unique issues, including consent for diagnosis and
treatment, confidentiality, parental notification, and mandatory reporting of sexual
activity.

Self-consent for diagnosis and treatment of STD is recognized in all 50 states.

However, state laws vary in terms of the specific infections defined as sexually
transmitted. This issue becomes more vague and complex in situations for which
surgical therapy and/or hospitalization are required. (See "Consent in adolescent
health care".)
Concerns about privacy and confidentiality are important barriers to seeking
medical care among adolescents with possible STD [15]. Specific discussion of
the meaning and limits of confidentiality increases disclosure of sensitive
information about symptoms, sexual activity, sexual partners, and preventive
behaviors [16]. (See "Confidentiality in adolescent health care".)

Pregnancy or fear of pregnancy sometimes motivates care-seeking with a chief

complaint of genital symptoms. (See "Pregnancy in adolescents", section on
'Diagnosis of pregnancy'.)

Most states have "age of consent" laws that require notification of child
protection authorities if sexual activity is identified, especially if there are large
discrepancies in the partners' ages. Ages vary among the states. Large age
discrepancies (>5 years) between partners are seen in approximately one-third of
adolescents with first sexual intercourse very early in adolescence (ie, ages 11 or
12 years) and in approximately one-tenth of adolescents who have their first
intercourse in middle or late adolescence [17]. (See "Confidentiality in
adolescent health care", section on 'Consensual sexual activity'.)

In surveys, physical and sexual violence from dating partners are reported by as
many as 20 percent of adolescent girls [18,19]. However, such acts are
infrequently reported to clinicians; questions regarding physical and sexual
dating violence should be included in clinical assessments of sexual behavior
and STD risk [20].

Self-treatment with topical medications, antibiotics, or douching are reported by

as many as 25 percent of adolescents with STD [21]. Symptomatic adolescent
females take approximately 10 days on average to seek care compared with only
approximately six days for symptomatic males [21].

Reporting of some STD is mandatory in all states, although the specific

organisms vary. Syphilis, gonorrhea, and acquired immunodeficiency syndrome
are reportable diseases in every state [22].

Iowa requires parental notification for HIV infection; the remainder of states do
not require parental notification, although notification is not expressly forbidden.
(See "Confidentiality in adolescent health care", section on 'Sexually transmitted
infections'.)

Inadvertent compromises of confidentiality by pharmacists or other medical

personnel. A study from Indiana University shows that 30 percent of pharmacists
would call parents about a prescription for antibiotics used to treat STD [23].
(See "Confidentiality in adolescent health care", section on 'Potential threats to
confidentiality'.)

As many as 20 percent of adolescents may fail to fill prescriptions for STD

treatment. Thus, single-dose, observed therapy may be preferable when
available.

Many adolescents may prefer to notify partners themselves [24]. However, this
strategy means that a substantial number of partners are never notified. Because
many adolescents have additional sexual contact with these partners, clinician
counseling to reinforce the importance of notification may be useful [25-27].

EVALUATION Routine assessment of sexual activity is an essential element of

STD-related care. However, a substantial proportion of adolescents are not evaluated for
risk of acquiring STD during office visits. This failure applies to both established and
new patients, as well as those who have demonstrated risk factors [28,29].
Sexual history The sexual history (table 1) should be straightforward and
nonjudgmental, with appropriate counseling regarding risk-taking behaviors, as
necessary [30,31]. An assurance of confidentiality is an important aspect of obtaining an
accurate sexual history in adolescents; additional aspects are discussed separately. (See
"Confidentiality in adolescent health care" and "Adolescent sexuality", section on
'Health care provider issues'.)
Examination In many circumstances, a careful sexual history, a review of symptoms,
and patient-obtained screening tests may replace routine pelvic examinations. Pelvic
examinations are sources of substantial anxiety and discomfort for many adolescents
[32,33]. Rather than a routine aspect of STD testing, genital examinations should be
reserved for evaluation of specific symptoms or to complete evaluation of a specific
differential diagnosis [33,34].
An external genital examination is indicated for evaluation of genital lesions that may
be caused by genital herpes, primary syphilis, or HPV. Menstrual irregularities (eg,
amenorrhea not because of pregnancy, and prolonged or heavy vaginal bleeding) and
abdominal and pelvic pain and tenderness may be important reasons for performing a
speculum and bimanual pelvic examination [33]. A speculum examination is indicated
for vaginal discharges that may be caused by a forgotten tampon, condom fragments, or
other objects.
Testing for STD using urine or other patient-obtained specimens is well accepted, and
often preferred, by adolescents and offers a useful alternative to pelvic examinations
[35-38]. As an example, adolescents preferred providing a urine sample to a vaginal
swab obtained themselves or to a pelvic examination when all three were performed in a

sample of 155 ethnically diverse patients referred for STD screening [37]. However, a
self-administered vaginal swab was the second choice for these patients over a pelvic
examination, and other studies demonstrate a high degree of acceptability of selfobtained vaginal swabs among adolescents [36,39]. Self-obtained vaginal specimens
work at least as well as other specimen types in conjunction with nucleic acid
amplification tests [40,41]. Although not FDA approved, self-obtained vaginal swabs
may be used for gonorrhea and chlamydia amplification testing but not for commonly
used direct hybridization probe tests. (See 'Nucleic acid amplification tests' below.)
Papanicolaou smear The need for Papanicolaou (PAP) smear screening for cervical
cancer and its precursors is another indication for performing a speculum pelvic
examination. Recommendations of professional organizations for age at initiation of
screening are discussed separately. (See "Screening for cervical cancer", section on
'Recommendations of professional organizations'.)
Although adolescents' PAP smears often are abnormal because of the presence of HPV
infection, these lesions typically resolve within eight months [42]. (See "Cervical
cytology: Evaluation of atypical squamous cells (ASC-US and ASC-H)", section on
'Adolescents'.)
PAP smears are indicated to screen for and follow cervical abnormalities. They should
not be used to routinely screen for HPV. Likewise, DNA and RNA tests for HPV should
not be used for HPV screening because the results do not alter clinical management
[31]. HPV infections are not curable, and there is no evidence that screening influences
risk of transmission. (See "Treatment and prevention of human papillomavirus
infections".)
Newer PAP smear techniques (ie, liquid-based cytology) offer the possibility of
simultaneous testing for other sexually transmitted organisms, such as Chlamydia [43].
However, these tests have not yet received extensive evaluation in adolescents.
STD CLINICAL PATTERNS A useful clinical approach to evaluating STD in all
patients, including adolescents, is based upon the pattern of presenting symptoms and
signs. These patterns can be useful initial guides for obtaining additional history and
performing examination and laboratory testing. The symptoms and signs associated
with STD in adolescents do not differ significantly from those in adults. Clinicians
should bear in mind that asymptomatic or minimally symptomatic presentations are
common occurrences.
Discharge syndromes Urethral/vaginal discharge and dysuria are the hallmarks of
gonorrhea, chlamydia, trichomoniasis, bacterial vaginosis, and candidiasis. Mycoplasma
genitalium infections are increasingly recognized as causes of sexually transmitted
discharge syndromes in adolescents and young adults [44]. Genital herpes is sometimes
associated with dysuria and a scant, mucoid urethral discharge, but nearly always in
association with other genital lesions. These conditions are discussed separately. (See
appropriate topic reviews).
Characteristics of the discharge, such as color (eg, clear, mucoid, yellow, green) are
unreliable indicators of the etiology. (See "Diagnostic approach to women with vaginal
discharge or vulvovaginal symptoms".)

Genital ulcer syndrome In the United States, genital herpes is the most common
cause of genital ulcer syndrome (GUS) among adolescents. Symptomatic genital herpes
may be caused by herpes simplex virus (HSV) type 1 in addition to the more common
HSV-2, and the proportion of cases caused by the former appears to be increasing [45].
Speculation that this increase is because of increased prevalence of oral-genital contact
among adolescents is unproven. (See "Approach to the patient with genital ulcers" and
"Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus
infection".)
Primary syphilis also is an important diagnostic consideration, especially in the setting
of commercial sex work or crack cocaine use. Only 0.4 percent of females and 0.1
percent of males entering the Job Corps have a positive screening test for syphilis,
suggesting that routine screening of asymptomatic, low-risk adolescents is not
warranted. (See "Pathogenesis, clinical manifestations, and treatment of early syphilis".)
However, some adolescents may participate in high-risk sexual networks (eg,
commercial sex work or crack cocaine use) that increase the possibility of syphilis as a
cause of genital ulcers. More aggressive syphilis screening for these populations may be
warranted. The clinical ascertainment of the etiology of GUS is unreliable because the
features of infections associated with GUS overlap and because mixed infections occur
in as many as 10 percent of cases [46]. Thus, syphilis serologic testing should be
included in the evaluation of GUS. (See "Diagnostic testing for syphilis".)
Less common causes of GUS in the United States, and extremely rare in adolescents,
include chancroid, lymphogranuloma venereum (LGV), and granuloma inguinale
(Calymmatobacterium granulomatis). (See "Chancroid" and "Lymphogranuloma
venereum" and "Approach to the patient with genital ulcers".)
Genital ulcers are not always due to sexually transmitted organisms. Nonsexually
transmitted vulvar ulcers (sometimes called Lipschutz ulcers, virginal ulcers, or
aphthous ulcers) may occur in association with viral illness, Crohn's disease, vasculitis,
and Behcet's disease (picture 1). (See "Vulvovaginal complaints in the prepubertal
child", section on 'Vulvar ulcers'.)
Pelvic inflammatory disease Pelvic inflammatory disease (PID) is a common sequela
of genital gonorrhea and chlamydia infections. Douching may increase the risk of
developing PID, especially when performed frequently [47]. Regular douching is
reported by 15 percent of adolescent women, with substantially higher proportions in
some ethnic groups [48]. PID can be a subclinical infection, and diagnosis may be
difficult to make. (See "Pathogenesis of and risk factors for pelvic inflammatory
disease" and "Clinical features and diagnosis of pelvic inflammatory disease" and
"Treatment of pelvic inflammatory disease".)
Dermatologic syndromes The most common STD with primarily dermatologic
presentation is genital warts (condyloma acuminata) caused by HPV. HPV types 6 and
11 are the most common causes of genital warts. However, types 16, 18, and 52 (not
typically associated with warts) are the most commonly identified HPV infections.
Mixed infections with more than one HPV type may account for one-half or more of
infections. (See "Condylomata acuminata (anogenital warts)".)

Skin rash is a common manifestation of secondary syphilis (picture 2). Condyloma lata
are another dermatologic manifestation of secondary syphilis. They are characterized by
large, raised, gray to white lesions, involving warm, moist areas such as mucous
membranes in the mouth and perineum (picture 3 and picture 4). Secondary syphilis is
an uncommon event in adolescents except in areas marked by high-risk sexual
networks, commercial sex work, and cocaine use. When secondary syphilis is seen in
adolescents, it typically reflects delayed care-seeking for primary syphilis lesions
(chancres) (picture 5). (See "Pathogenesis, clinical manifestations, and treatment of
early syphilis".)
Skin rash is also a common manifestation of disseminated gonococcal infection (picture
6). (See "Disseminated gonococcal infection".)
Pediculosis pubis, caused by the crab louse (picture 7), and scabies, which may be
transmitted by sexual activity, also present with dermatologic complaints. (See
"Pediculosis pubis and pediculosis ciliaris" and "Scabies".)
SCREENING AND DIAGNOSTIC TESTING Sexually active adolescent patients
should be screened at least annually for gonorrhea and chlamydia [4,22,49]. In addition,
patients who have particular risk factors (table 2) should be screened annually for HIV
and syphilis [22,49,50]. (See "Screening for sexually transmitted diseases".)
In 2006 the CDC recommended that "opt-out" HIV testing be routinely offered to all
patients aged 13 to 64 years [51]. "Opt-out" testing involves informing the patient,
orally or in writing, that HIV testing will be performed unless he or she declines. The
Society for Adolescent Health and Medicine also supports offering HIV testing as part
of routine care for sexually active adolescents [50]. (See "Serologic screening for HIV
infection", section on 'Opt-out testing'.)
Tests available for the detection of STD include light microscopy, culture, serology, and
several DNA probe or nucleic acid amplification methods. Each of these tests has an
ongoing role in screening (ie, case-finding in at-risk, asymptomatic patients) or in
clinical diagnosis. The Centers for Disease Control and Prevention (CDC) has published
an excellent review of diagnostic methods for gonococcal and chlamydial infections
[52]. (See "Screening for sexually transmitted diseases".)
Microscopy Microscopy includes examination of vaginal fluid mixed with saline and
with potassium hydroxide, and Gram stain. Self-obtained vaginal swabs perform
comparably to clinician-obtained swabs and are well accepted by adolescent patients
[36,37,39].
The conditions for which microscopy are useful include:

Trichomoniasis. The sensitivity of saline wet mount for diagnosis of

trichomoniasis is considered to be 50 to 70 percent. Rapid tests for Trichomonas
that have increased sensitivity compared with saline wet mount are available, but
there is little published information about their use in adolescent patients. (See
"Trichomonas vaginalis", section on 'Diagnosis'.)
Bacterial vaginosis. (See "Bacterial vaginosis", section on 'Diagnosis'.)

Vaginal candidiasis. (See "Candida vulvovaginitis", section on 'Office

diagnosis'.)

Gonococcal and non-gonococcal urethritis (in males). Gram stain (ie, finding of
gram-negative intracellular diplococci) is both sensitive and specific (94, and 94
to 97 percent, respectively) for the diagnosis of gonococcal urethritis in
symptomatic males [53,54]. Non-gonococcal urethritis is diagnosed by finding
five or more PMN per oil-immersion microscopic (1000x) field in the absence
of gram-negative intracellular diplococci [55].

Performing Gram stain of cervical secretions in females is not recommended unless

other diagnostic modes are unavailable. Gram stain of cervical secretions has a low
sensitivity for diagnosing gonorrhea and a low specificity for diagnosing mucopurulent
cervicitis.
Culture Culture is used widely for the diagnosis of gonorrhea, chlamydia, and genital
herpes. (See appropriate topic reviews).
A relatively inexpensive self-contained culture system for Trichomonas is available. The
culture system may be preferable to microscopy because it has greater sensitivity [56].
(See "Trichomonas vaginalis", section on 'Diagnosis'.)
Serology Serologic tests for HSV type 2 that identify circulating antibodies to
specific herpes glycoproteins are available. The tests are highly sensitive and detect
seroconversion within two to three weeks after initial infection. (See "Epidemiology,
clinical manifestations, and diagnosis of genital herpes simplex virus infection", section
on 'Serology'.)
Syphilis serology remains substantially dependent upon non-treponemal (eg, RPR or
VDRL) screening tests followed by treponemal (eg, FTA) screening tests. Reasonably
common causes of false-positive screening tests in adolescents include pregnancy,
injection drug use, acute hepatitis B, and systemic lupus erythematosus. (See
"Diagnostic testing for syphilis".)
Nucleic acid amplification tests NAATs are highly sensitive tests for N. gonorrhoeae
and C. trachomatis that can be performed on genital specimens (urethral or cervical), as
well as urine.
The sensitivity of urine-based NAATs is decreased slightly compared with that of
urethral/cervical specimens but is comparable or superior to traditional cultures [52]. An
NAAT with vaginal specimens (obtained by the patient or by a clinician) appears to be
equivalent to that from cervical specimens [57].
The CDC suggests the following strategy for screening for C. trachomatis and N.
gonorrhoeae [52].

For women, cervical specimens assessed by an NAAT or culture if pelvic

examination is performed; otherwise, an NAAT using a urine specimen is
preferred.

For men, an NAAT or culture if endourethral swab specimens are obtained;

otherwise, an NAAT using a urine specimen is preferred [52].

Several NAATs are commercially available (table 3). These tests differ somewhat in the
method of nucleic acid amplification and in the targeted nucleic acid sequences but
demonstrate comparable sensitivity and specificity [52]. Choice of one test over another
for screening and diagnostic purposes is largely a matter of local laboratory preference.
Tests based on nucleic acid hybridization also are commercially available for detection
of N. gonorrhoeae and C. trachomatis. These tests can be performed on a single
specimen. However, additional tests are required for organism-specific results [52].
Urine screening for gonorrhea, chlamydia, or both using NAAT has been used
successfully in difficult-to-reach adolescents ("street kids"), as well as in pediatric
emergency departments and school-based settings [58-62]. Screening in school-based
settings was associated with significant reduction in chlamydia rates during a one-year
period [62].
TREATMENT Almost no clinical trials of STD-related pharmaceuticals include
participants younger than 16 years of age, and relatively few include 16- to 17-yearolds. Most data regarding safety and efficacy are extrapolated from late adolescents and
young adults. Guidelines for the treatment of specific STD are regularly updated by the
CDC and are available on its Web site, www.cdc.gov/std/ [31]. (See individual topic
reviews on sexually transmitted infections.)
As many as 20 percent of adolescents may fail to fill prescriptions for STD treatment.
Thus, single-dose, observed therapy may be preferable when available. Additional
issues related to the treatment of STD that are particularly relevant in adolescent
patients (eg, confidentiality, parental notification) are discussed above. (See 'Unique
issues in adolescents' above.)
Expedited partner therapy Expedited partner therapy (EPT) refers to the provision of
appropriate single-dose antibiotics to patients with chlamydia or gonorrhea for delivery
to partners. EPT is endorsed by the Society for Adolescent Health and Medicine and the
American Academy of Pediatrics as a strategy for ensuring partner treatment [63].
Additional information may be found at www.cdc.gov/std/ept.
Reinfection A high prevalence of C. trachomatis and N. gonorrhoeae (reinfection
rather than treatment failure) is observed in patients who were treated for STD in the
preceding months [64-67]. Women and men recently treated for chlamydia or gonorrhea
should be retested approximately three months after treatment is completed and
whenever they next seek medical care within the following 3 to 12 months (whether or
not the patient thinks that the partner was treated) [31].
INFORMATION FOR PATIENTS UpToDate offers two types of patient education
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four or five key questions a patient might have about a given condition. These articles
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and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you
to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on patient info and the keyword(s) of
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Basics topics (see "Patient information: Teen sexuality (The Basics)")

Beyond the Basics topics (see "Patient information: Adolescent sexuality")

SUMMARY

Adolescence is a heterogeneous developmental period in terms of sexual

behavior and risk of acquiring sexually transmitted diseases (STD). Behavioral
and biologic factors contribute to the high levels of sexual activity and
acquisition of STD in late adolescence; recurrent infection with sexually
transmitted organisms is common. (See 'Risk factors' above.)
The evaluation and treatment of STD in adolescents raises a number of unique
issues, including consent for diagnosis and treatment, adherence to therapy,
confidentiality, parental notification, partner notification, and mandatory
reporting of sexual activity. (See 'Unique issues in adolescents' above.)

A careful sexual history, review of symptoms, and patient-obtained screening

tests may replace routine pelvic examinations in many cases. Testing for STD
using urine or other patient-obtained specimens is well accepted by adolescents
and offers a useful alternative to pelvic examinations. (See 'Screening and
diagnostic testing' above and 'Evaluation' above.)

Speculum examinations are not routinely necessary in the evaluation for

sexually transmitted infections in female adolescents. However, they are
indicated in girls with menstrual irregularities, abdominal and pelvic pain and
tenderness, vaginal discharge that may be caused by a foreign body (eg,
forgotten tampon, condom fragment), and to screen for cervical cancer. (See
'Examination' above.)

The pattern of presenting symptoms and signs of STD can guide the need for
additional information from the history, examination, and/or laboratory. (See
'STD clinical patterns' above.)

Guidelines for the treatment of specific STD are regularly updated by the CDC
and are available on its Web site (www.cdc.gov/std). (See 'Treatment' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted
infections among female adolescents aged 14 to 19 in the United States.
Pediatrics 2009; 124:1505.
2. STD Surveillance 2009. Centers for Disease Control and Prevention. Available
at: www.cdc.gov/std/stats/. (Accessed on December 29, 2010).
3. Fortenberry JD, Brizendine EJ, Katz BP, et al. Subsequent sexually transmitted
infections among adolescent women with genital infection due to Chlamydia
trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. Sex Transm Dis
1999; 26:26.
4. Tu W, Batteiger BE, Wiehe S, et al. Time from first intercourse to first sexually
transmitted infection diagnosis among adolescent women. Arch Pediatr Adolesc
Med 2009; 163:1106.
5. Kahn JA, Rosenthal SL, Succop PA, et al. Mediators of the association between
age of first sexual intercourse and subsequent human papillomavirus infection.
Pediatrics 2002; 109:E5.
6. Shew ML, Fortenberry JD, Miles P, Amortegui AJ. Interval between menarche
and first sexual intercourse, related to risk of human papillomavirus infection. J
Pediatr 1994; 125:661.
7. Burstein GR, Gaydos CA, Diener-West M, et al. Incident Chlamydia trachomatis
infections among inner-city adolescent females. JAMA 1998; 280:521.
8. Fortenberry JD. Adolescent substance use and sexually transmitted diseases risk:
a review. J Adolesc Health 1995; 16:304.
9. Leigh BC. Alcohol and condom use: a meta-analysis of event-level studies. Sex
Transm Dis 2002; 29:476.
10. Niccolai LM, Ethier KA, Kershaw TS, et al. New sex partner acquisition and
sexually transmitted disease risk among adolescent females. J Adolesc Health
2004; 34:216.
11. Centers for Disease Control and Prevention (CDC). Trends in sexual risk
behaviors among high school students--United States, 1991-2001. MMWR
Morb Mortal Wkly Rep 2002; 51:856.
12. Moscicki AB, Ma Y, Holland C, Vermund SH. Cervical ectopy in adolescent
girls with and without human immunodeficiency virus infection. J Infect Dis
2001; 183:865.
13. McGrath JW, Strasburger VC, Cushing AH. Secretory IgA in cervical mucus. J
Adolesc Health 1994; 15:423.
14. Ellen JM, Lammel CJ, Shafer MA, et al. Cervical secretory immunoglobulin A
in adolescent girls. J Adolesc Health 1999; 25:150.
15. Ford CA, Best D, Miller WC. The pediatric forum: confidentiality and
adolescents' willingness to consent to sexually transmitted disease testing. Arch
Pediatr Adolesc Med 2001; 155:1072.

16. Thrall JS, McCloskey L, Ettner SL, et al. Confidentiality and adolescents' use of
providers for health information and for pelvic examinations. Arch Pediatr
Adolesc Med 2000; 154:885.
17. Leitenberg H, Saltzman H. A statewide survey of age at first intercourse for
adolescent females and age of their male partners: relation to other risk
behaviors and statutory rape implications. Arch Sex Behav 2000; 29:203.
18. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against
adolescent girls and associated substance use, unhealthy weight control, sexual
risk behavior, pregnancy, and suicidality. JAMA 2001; 286:572.
19. Wilson KM, Klein JD. Opportunities for appropriate care: health care and
contraceptive use among adolescents reporting unwanted sexual intercourse.
Arch Pediatr Adolesc Med 2002; 156:341.
20. Shrier LA, Pierce JD, Emans SJ, DuRant RH. Gender differences in risk
behaviors associated with forced or pressured sex. Arch Pediatr Adolesc Med
1998; 152:57.
21. Fortenberry JD. Health care seeking behaviors related to sexually transmitted
diseases among adolescents. Am J Public Health 1997; 87:417.
22. American College of Obstetricians and Gynecologists Committee on Adolescent
Health Care. ACOG Committee Opinion #301: Sexually transmitted diseases in
adolescents. Obstet Gynecol 2004; 104:891.
23. Conard LA, Fortenberry JD, Blythe MJ, Orr DP. Pharmacists' attitudes toward
and practices with adolescents. Arch Pediatr Adolesc Med 2003; 157:361.
24. Oh MK, Boker JR, Genuardi FJ, et al. Sexual contact tracing outcome in
adolescent chlamydial and gonococcal cervicitis cases. J Adolesc Health 1996;
18:4.
25. Fortenberry JD, Brizendine EJ, Katz BP, Orr DP. Post-treatment sexual and
prevention behaviours of adolescents with sexually transmitted infections. Sex
Transm Infect 2002; 78:365.
26. Fortenberry JD, Brizendine EJ, Katz BP, Orr DP. The role of self-efficacy and
relationship quality in partner notification by adolescents with sexually
transmitted infections. Arch Pediatr Adolesc Med 2002; 156:1133.
27. Niccolai LM, Ickovics JR, Zeller K, et al. Knowledge of sex partner treatment
for past bacterial STI and risk of current STI. Sex Transm Infect 2005; 81:271.
28. Halpern-Felsher BL, Ozer EM, Millstein SG, et al. Preventive services in a
health maintenance organization: how well do pediatricians screen and educate
adolescent patients? Arch Pediatr Adolesc Med 2000; 154:173.
29. Ellen JM, Lane MA, McCright J. Are adolescents being screened for sexually
transmitted diseases? A study of low income African American adolescents in
San Francisco. Sex Transm Infect 2000; 76:94.

30. Torkko KC, Gershman K, Crane LA, et al. Testing for Chlamydia and sexual
history taking in adolescent females: results from a statewide survey of Colorado
primary care providers. Pediatrics 2000; 106:E32.
31. Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC).
Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep
2010; 59:1.
32. Larsen SB, Kragstrup J. Experiences of the first pelvic examination in a random
samples of Danish teenagers. Acta Obstet Gynecol Scand 1995; 74:137.
33. Braverman PK, Breech L, Committee on Adolescence. American Academy of
Pediatrics. Clinical report--gynecologic examination for adolescents in the
pediatric office setting. Pediatrics 2010; 126:583.
34. Shafer MA, Pantell RH, Schachter J. Is the routine pelvic examination needed
with the advent of urine-based screening for sexually transmitted diseases? Arch
Pediatr Adolesc Med 1999; 153:119.
35. Cohen DA, Nsuami M, Martin DH, Farley TA. Repeated school-based screening
for sexually transmitted diseases: a feasible strategy for reaching adolescents.
Pediatrics 1999; 104:1281.
36. Wiesenfeld HC, Lowry DL, Heine RP, et al. Self-collection of vaginal swabs for
the detection of Chlamydia, gonorrhea, and trichomoniasis: opportunity to
encourage sexually transmitted disease testing among adolescents. Sex Transm
Dis 2001; 28:321.
37. Serlin M, Shafer MA, Tebb K, et al. What sexually transmitted disease screening
method does the adolescent prefer? Adolescents' attitudes toward first-void
urine, self-collected vaginal swab, and pelvic examination. Arch Pediatr Adolesc
Med 2002; 156:588.
38. Tebb KP, Paukku MH, Pai-Dhungat MR, et al. Home STI testing: the adolescent
female's opinion. J Adolesc Health 2004; 35:462.
39. Smith K, Harrington K, Wingood G, et al. Self-obtained vaginal swabs for
diagnosis of treatable sexually transmitted diseases in adolescent girls. Arch
Pediatr Adolesc Med 2001; 155:676.
40. Hobbs MM, van der Pol B, Totten P, et al. From the NIH: proceedings of a
workshop on the importance of self-obtained vaginal specimens for detection of
sexually transmitted infections. Sex Transm Dis 2008; 35:8.
41. Fang J, Husman C, DeSilva L, et al. Evaluation of self-collected vaginal swab,
first void urine, and endocervical swab specimens for the detection of
Chlamydia trachomatis and Neisseria gonorrhoeae in adolescent females. J
Pediatr Adolesc Gynecol 2008; 21:355.
42. Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline
for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002;
52:342.

43. Bianchi A, Moret F, Desrues JM, et al. PreservCyt transport medium used for the
ThinPrep Pap test is a suitable medium for detection of Chlamydia trachomatis
by the COBAS Amplicor CT/NG test: results of a preliminary study and future
implications. J Clin Microbiol 2002; 40:1749.
44. Tosh AK, Van Der Pol B, Fortenberry JD, et al. Mycoplasma genitalium among
adolescent women and their partners. J Adolesc Health 2007; 40:412.
45. Langenberg AG, Corey L, Ashley RL, et al. A prospective study of new
infections with herpes simplex virus type 1 and type 2. Chiron HSV Vaccine
Study Group. N Engl J Med 1999; 341:1432.
46. DiCarlo RP, Martin DH. The clinical diagnosis of genital ulcer disease in men.
Clin Infect Dis 1997; 25:292.
47. Ness RB, Soper DE, Holley RL, et al. Douching and endometritis: results from
the PID evaluation and clinical health (PEACH) study. Sex Transm Dis 2001;
28:240.
48. Merchant JS, Oh K, Klerman LV. Douching: a problem for adolescent girls and
young women. Arch Pediatr Adolesc Med 1999; 153:834.
49. Recommendations for preventive pediatric health care. Pediatrics 2007;
120:1376. Available at: practice.aap.org/content.aspx?aid=1599. (Accessed on
February 7, 2008).
50. D'Angelo LJ, Samples C, Rogers AS, et al. HIV infection and AIDS in
adolescents: an update of the position of the Society for Adolescent Medicine. J
Adolesc Health 2006; 38:88.
51. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for
HIV testing of adults, adolescents, and pregnant women in health-care settings.
MMWR Recomm Rep 2006; 55:1.
52. Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia
trachomatis and Neisseria gonorrhoeae infections--2002. MMWR Recomm Rep
2002; 51:1.
53. Sherrard J, Barlow D. Gonorrhoea in men: clinical and diagnostic aspects.
Genitourin Med 1996; 72:422.
54. Goodhart ME, Ogden J, Zaidi AA, Kraus SJ. Factors affecting the performance
of smear and culture tests for the detection of Neisseria gonorrhoeae. Sex
Transm Dis 1982; 9:63.
55. Bornstein J, Lakovsky Y, Lavi I, et al. The classic approach to diagnosis of
vulvovaginitis: a critical analysis. Infect Dis Obstet Gynecol 2001; 9:105.
56. Hook EW 3rd. Trichomonas vaginalis--no longer a minor STD. Sex Transm Dis
1999; 26:388.
57. Hook EW 3rd, Ching SF, Stephens J, et al. Diagnosis of Neisseria gonorrhoeae
infections in women by using the ligase chain reaction on patient-obtained
vaginal swabs. J Clin Microbiol 1997; 35:2129.

58. Auerswald CL, Sugano E, Ellen JM, Klausner JD. Street-based STD testing and
treatment of homeless youth are feasible, acceptable and effective. J Adolesc
Health 2006; 38:208.
59. Monroe KW, Weiss HL, Jones M, Hook EW 3rd. Acceptability of urine
screening for Neisseria gonorrheae and Chlamydia trachomatis in adolescents at
an urban emergency department. Sex Transm Dis 2003; 30:850.
60. Aldeen T, Haghdoost A, Hay P. Urine based screening for
asymptomatic/undiagnosed genital chlamydial infection in young people visiting
the accident and emergency department is feasible, acceptable, and can be
epidemiologically helpful. Sex Transm Infect 2003; 79:229.
61. Rietmeijer CA, Bull SS, Ortiz CG, et al. Patterns of general health care and STD
services use among high-risk youth in Denver participating in community-based
urine chlamydia screening. Sex Transm Dis 1998; 25:457.
62. Cohen DA, Nsuami M, Etame RB, et al. A school-based Chlamydia control
program using DNA amplification technology. Pediatrics 1998; 101:E1.
63. Burstein GR, Eliscu A, Ford K, et al. Expedited partner therapy for adolescents
diagnosed with chlamydia or gonorrhea: a position paper of the Society for
Adolescent Medicine. J Adolesc Health 2009; 45:303.
64. Kjaer HO, Dimcevski G, Hoff G, et al. Recurrence of urogenital Chlamydia
trachomatis infection evaluated by mailed samples obtained at home: 24 weeks'
prospective follow up study. Sex Transm Infect 2000; 76:169.
65. Whittington WL, Kent C, Kissinger P, et al. Determinants of persistent and
recurrent Chlamydia trachomatis infection in young women: results of a
multicenter cohort study. Sex Transm Dis 2001; 28:117.
66. Oh MK, Cloud GA, Fleenor M, et al. Risk for gonococcal and chlamydial
cervicitis in adolescent females: incidence and recurrence in a prospective cohort
study. J Adolesc Health 1996; 18:270.
67. Thomas JC, Weiner DH, Schoenbach VJ, Earp JA. Frequent re-infection in a
community with hyperendemic gonorrhoea and chlamydia: appropriate clinical
actions. Int J STD AIDS 2000; 11:461.